Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ahva Care Of Winfield during CMS and state inspections, most recent first.
Failure to Provide Bed Hold Notices and Written Transfer Documentation: The facility did not provide bed hold notices or written documentation for the reason for hospital transfer for 5 residents reviewed. Records for residents with intact cognition showed transfers to the ED/hospital for conditions such as sepsis, PE, chest pain, and other acute issues, but there was no documentation that the residents or their POAs received the required written notice. The DON stated the facility usually only called the POA and did not provide written notification.
Bedtime snacks were not routinely offered or provided to all residents. Five residents reported that snacks were only given to some people, were placed on dinner trays, and were no longer brought to the dining room for everyone; they said residents who wanted snacks had to buy them from the activity table and were hungry between dinner and breakfast. RN, dietary, and DON interviews confirmed that snacks were not routinely offered, were mainly provided for residents with orders or DM, and the five residents reviewed had no bedtime snack orders despite a facility policy stating bedtime nourishments would be provided after the evening meal.
Inadequate Shower Water Temperature: A resident reported that a preferred, more private shower room had cold water for over a year and was uncomfortable to use. The MTD said the resident had complained, but his test of the shower with the water turned fully hot reached only 93°F, below the facility's stated 100-110°F range. The resident had intact cognition and a care plan that included staff help with adjusting water temperature to a comfortable level.
Failure to provide and assist with resident activities: A resident with severely impaired vision stated she liked music, trivia, and exercise, but staff were too busy to help her participate. She said she could not join activities like bingo because she is blind and was not always told what activities were available because the schedule was not read to her. The resident also reported being left in the activity area after one event ended. The AD stated the resident liked music-related activities and going outside, but the activities provided were mainly room visits and POA visits, and no staff member was assigned to assist her during group activities.
Improper Bedside Storage of Medications: A resident with dementia and multiple psychiatric diagnoses kept an inhaler at the bedside without an order or assessment for bedside storage, and two other residents also had medications left on over-bed tables or nightstands. Staff said residents were not allowed to keep meds in their rooms unless ordered and assessed, and the facility policy required meds to be stored in locked compartments.
Failure to provide built up eating utensils for a resident who needed them. During a meal observation, the resident struggled to feed herself and dropped food on her chest while stating she had a hard time handling her spoon. Her meal ticket and physician diet order both indicated built up utensils, and staff stated CNAs are responsible for ensuring the meal tray is correct and that residents have the utensils they need.
Two residents with psychiatric and medical conditions engaged in a physical altercation after a verbal dispute, resulting in both individuals hitting each other before staff intervened. The incident was witnessed by staff, documented in the EMR, and reported to the abuse coordinator. Both residents were cognitively intact and had a history of behavioral issues, but the facility failed to prevent the physical abuse as required by policy.
The facility failed to maintain a clean and comfortable environment for residents, as observed in four cases. Residents reported cold room temperatures, with one room confirmed at 63°F, below the policy range. A broken thermostat was identified as a cause. Additionally, a resident's room was found unclean, with a dirty urinal on the meal tray. These issues indicate non-compliance with the facility's policy on maintaining a homelike environment.
The facility failed to manage controlled medications properly and ensure the availability of as-needed medications. Controlled substances were improperly stored and not disposed of as required, and a resident's hemorrhoid cream was unavailable despite being ordered. The facility's policies on medication management were not followed.
A facility failed to ensure a resident's call light was within reach, leading to a deficiency in accommodating resident needs. The resident, who requires substantial assistance and is at risk for falls, reported that staff often leave the call button out of reach, resulting in a previous fall. The DON confirmed that staff should ensure call lights are accessible.
A facility failed to maintain accurate advanced directives for three residents, as discrepancies were found between their POLST forms and EMRs. Two residents had DNR orders on their POLST forms but were listed as full code in their EMRs, while another resident's EMR lacked a code status order. The Social Worker confirmed the DNR wishes, but the facility's policy requiring prominent display of advance directives in medical records was not followed.
A hospice resident experienced an unwitnessed fall and was transferred to the hospital without timely notification to the POA, physician, and hospice provider. The resident, who had an order not to be hospitalized, was admitted to the hospital for dehydration and abnormal sodium levels. The facility's policy requires immediate notification of significant changes, which was not followed, leading to the resident's hospitalization against the care plan.
A facility failed to follow a hospice physician's order for a resident who was not to be hospitalized. Despite the order, the resident was sent to the hospital after an unwitnessed fall. The RN involved was unaware of the order, and the hospice nurse was informed only after the hospitalization. The facility's policy mandates adherence to physician orders and notifying the provider upon a change in condition.
The facility failed to safely transfer three residents using mechanical lifts, resulting in unsafe practices. Residents with conditions like muscle weakness and hemiplegia were transferred with slings that were too loose and without necessary knee belt attachments. Staff were unsure about the appropriate use and sizing of equipment, leading to compromised resident safety.
A resident's extended-release antihypertensive medication, Diltiazem ER, was improperly administered by a nurse who crushed the tablet before giving it to the resident. This action was against the medication's administration instructions and the facility's policy, leading to a significant medication error.
Failure to Provide Bed Hold Notices and Written Transfer Documentation
Penalty
Summary
The facility failed to provide residents and/or their POA with a bed hold notice and written documentation for the reason for transfer to the hospital for 5 of 5 residents reviewed for transfers. The report identified residents R1, R2, R10, R129, and R138 as having hospital transfers without documentation in the medical record showing that a bed hold notice was given or that written information explaining the transfer was provided to the resident or representative. In several cases, the record also lacked any uploaded bed hold notice in the documents/forms section. For R1, the record showed multiple transfers to the hospital, including one for a change in mental status and another for a suspected medication reaction, with the POA and DON notified and the resident later returning to the facility. R1 was cognitively intact per MDS and stated she was never given a bed hold notice or anything in writing for the reason for transfer. For R10, the record showed transfer to the ED for chest pain and shortness of breath, followed by admission for pulmonary embolism and later return to the facility; R10 was also cognitively intact and stated she was never given a bed hold notice or written explanation for the transfer. The record review found no documentation that either resident received the required written notice. R129 and R138 also had hospital transfers with no copy of a written bed hold notification available in the record, and R129 stated the facility did not provide her with a bed hold notification or explain that the bed would be available upon return. R2’s record showed multiple hospital transfers, including one on 5/10/26 and several earlier transfers, but there was no documentation that a bed hold notice was completed or that written documentation for the reason for transfer was given to the resident or POA for any of the hospitalizations. The DON stated the facility did not have bed hold notices for R1 and R10, that they were not done, and that the facility usually only called the POA rather than notifying residents or families in writing.
Bedtime snacks were not routinely offered or provided
Penalty
Summary
Meals and snacks were not served at times in accordance with residents’ needs, preferences, and requests because bedtime snacks were not offered or provided to all residents. During a special Resident Council Meeting, five residents stated that bedtime snacks were only given to some residents, were placed with dinner trays, were not provided to everyone, and were only available to residents with a physician order. They reported that the facility had previously called all residents to the dining room for bedtime snacks but stopped doing so about two years earlier, and that residents who wanted snacks had to purchase them from the activity table. They also stated that snacks were not complimentary and that they were hungry between dinner and breakfast. Interviews with nursing and dietary staff showed that bedtime snacks were not routinely offered. Two RNs stated that bedtime snacks were placed on meal trays during dinner and that staff did not offer snacks. The Dietary Services Manager stated that bedtime snacks were placed on dinner trays for residents with orders and for residents with diabetes mellitus, and that for other residents snacks were given upon request after consulting the dietician. The DON stated that bedtime snacks go out with dinner trays and that staff do not routinely offer them. Review of the five residents’ POS showed no orders for bedtime snacks, even though the facility policy stated that bedtime nourishments would be provided at approximately bedtime and distributed by nursing after the evening meal.
Inadequate Shower Water Temperature
Penalty
Summary
The facility failed to provide a comfortable water temperature in a shower used by one resident, R82, who was reviewed for homelike environment concerns. R82 said the hallway shower she prefers to use did not have hot water, that she had raised the issue in resident council meetings, and that the shower temperature had been cold for over a year. She stated she preferred that shower room because it was more private, but the water was uncomfortable and she could not sit under it long enough to enjoy it, so she tried to get in and out quickly. The Maintenance Director said R82 reported the water was not getting hot enough, but he had checked it and believed it was okay. When he tested the shower by running the water for 6 minutes with the control turned fully to hot, the highest temperature recorded was 93 degrees Fahrenheit. He also stated hot water temperatures should range between 100 and 110 degrees Fahrenheit. The logbook documentation he provided did not have space to record the shower temperature in R82's shower room, which contains both a shower and a sink. R82's MDS showed intact cognition, and her care plan included staff assistance with adjusting water temperature to a comfortable temperature as needed.
Failure to Provide and Assist with Resident Activities
Penalty
Summary
The facility failed to offer and assist a resident with activities based on her interests and preferences. The resident stated she likes music, trivia, and exercise, but staff were too busy to assist her. She also stated she could not participate in activities such as bingo because she is blind, and she did not always know what activities were available because no one read the activity schedule to her. She reported that a previous activity ended with staff leaving her in the activity area, and a housekeeper later heard her scream and helped her back to her room. The resident’s record showed she had severely impaired vision and needed staff assistance and encouragement to attend and participate in facility activities. Her care plan stated she tended to isolate in her room and needed help reviewing the activity schedule, getting to and from activities, and with set-up and participation. The Activities Director stated the resident liked music-related activities and going outside, that activities staff saw her every other day for bedside activities, and that the activities provided were room visits to assist with meal selections and POA visits. The Activities Director also stated there was an activity where the resident was left behind in the activity area after it was over, and that during group activities there was not one staff member responsible for assisting her.
Improper Bedside Storage of Medications
Penalty
Summary
The facility failed to properly store medications for residents who were not assessed to keep medications at bedside. During observation, R31 had an Anoro Ellipta inhaler on the bedside table and later retrieved it from a top drawer, stating he got it from the nurse and would administer it himself. R31’s face sheet listed diagnoses including dementia, schizoaffective disorder, bipolar disorder, depression, epilepsy, cocaine abuse, delusional disorders, and chronic bronchitis. His MDS dated 04/14/26 showed mild cognitive impairment, but his POS did not include an order to store medications at the bedside, his care plan did not address medication storage, and the facility could not provide an assessment for bedside medication storage. Additional observations showed similar medication storage issues for other residents. R43 had fluticasone/salmeterol discus on her over-bed table, and she stated nurses always left it there for her to use. R97 had nystatin prescribed for another resident, R119, on his nightstand. Staff interviews indicated residents were not supposed to keep medications in their rooms unless they had a doctor’s order, an assessment, and a locked drawer, and the DON stated the facility did not have any residents allowed to keep medications at the bedside. The facility’s medication storage policy required medications to be stored in locked compartments and under direct observation during medication passes.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide built up eating utensils to support a resident’s independent eating. During a meal observation on 05/12/2026 at 12:09 PM, R3 struggled to feed herself and dropped food on her chest while stating she was having a hard time handling her spoon to feed herself. R3’s meal ticket listed built up utensils for all meals, and her physician diet order dated 1/14/26 included a no added salt, low concentrated sugar, pureed texture diet with regular thin consistency, built up utensils, and a divided plate. On 05/13/2026, a CNA stated that CNAs set up resident meal trays and are responsible for making sure the tray is correct, and that residents will struggle to eat their meal if they do not have the utensils they need. The DON stated residents are assessed by speech or occupational therapy for built up utensils. The facility policy stated adaptive equipment and utensils will be placed on the resident’s meal tray at each meal as indicated.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents' right to be free from physical abuse by another resident, as evidenced by an altercation between two residents. On June 7, 2025, two residents with multiple psychiatric and medical diagnoses engaged in a physical confrontation near the facility's elevator. Both residents exchanged words, which escalated into physical contact, including hitting and kicking. Staff intervened and separated the residents, but both admitted to hitting each other during the incident. Documentation in the electronic medical records and behavior monitoring indicated that both residents were observed to be physically aggressive and expressed frustration or anger towards others on the day of the incident. Staff members, including a CNA, confirmed witnessing the altercation and intervening to stop it. The incident was reported to the abuse coordinator, and body checks were performed, revealing no visible injuries or complaints of pain from either resident. Both residents were cognitively intact but had histories of psychiatric disorders, including schizoaffective disorder, bipolar disorder, and psychosis. The altercation was reportedly triggered by a dispute over bathroom use. The facility's policy requires the prevention of abuse and the provision of a safe environment, but the incident demonstrated a failure to prevent resident-to-resident physical abuse as required.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to provide a clean and comfortable environment for its residents, as evidenced by the observations and interviews conducted. Four residents were affected by this deficiency. One resident, who was cognitively intact, reported that her room was always cold, and she was observed covered with two comforters. Another resident also complained about the cold temperature in her room and was seen covered with a comforter. A third resident was observed wearing winter attire indoors due to the cold room temperature, which was confirmed to be 63°F, below the facility's policy range of 71 to 81°F. The Maintenance Director acknowledged the issue, noting that the thermostat in the resident's room was broken. Additionally, another resident was found in an unclean environment, with a foul odor emanating from his side of the room. His urinal, which was placed on his meal tray, had a dark brown substance around the rim, and the resident stated it had been dirty for a long time. This resident was also cognitively intact. The facility's policy on maintaining a homelike environment, which includes comfortable room temperatures and cleanliness, was not adhered to, leading to these deficiencies.
Deficiencies in Medication Management and Availability
Penalty
Summary
The facility failed to properly manage and dispose of controlled medications and ensure the availability of as-needed medications for residents. During an inspection, it was observed that a resident's Ativan tablets were improperly stored in a refrigerator and not logged in the narcotic control binder, despite being discontinued. Another resident's Lorazepam punch card had a pill slot taped over with a pill inside, indicating improper handling. Additionally, controlled medications for two discharged residents were not removed and disposed of as required, with their records not maintained in the narcotic control binder. The facility's policy mandates that discontinued controlled substances be destroyed in a controlled manner, which was not adhered to in these cases. Furthermore, a resident requested hemorrhoid cream, which was not available for administration despite being ordered by a physician. The LPN acknowledged the absence of the over-the-counter medication and had informed a supervisor days prior, but the issue was not resolved. The Director of Nursing confirmed that the medication was not covered by the resident's insurance but emphasized that medications should be available for residents. The facility's policy requires that all medications, including over-the-counter ones, be obtained and available for residents, which was not followed in this instance.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to maintain the call light within reach for a resident, identified as R130, which is a deficiency in accommodating the needs of residents. On February 18, 2025, R130 was observed sitting on the side of his bed with his call button draped over the side of his wheelchair, out of reach. R130 expressed concern about the difficulty in accessing the call button without risking a fall. He reported that staff often do not provide him with the call button, estimating this occurs 75% of the time. R130 also mentioned a previous fall that occurred when he attempted to reach for the call button. His Minimum Data Set (MDS) indicated intact cognition and a need for substantial assistance with personal hygiene, while his care plan highlighted a risk for falls and included interventions such as keeping the call light within reach. The Director of Nursing confirmed that staff should ensure the call light is accessible to residents when leaving the room.
Inaccurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to maintain accurate advanced directives in the residents' medical records, affecting three residents. A Licensed Practical Nurse (LPN) discovered discrepancies between the residents' POLST forms and their Electronic Medical Records (EMRs). Specifically, two residents had POLST forms indicating Do Not Resuscitate (DNR) orders, but their EMRs showed full code orders, which means they were to be resuscitated. Another resident's EMR did not have any code status order, despite having a POLST form indicating DNR. The LPN confirmed that the information in the DNR binder, which contained the POLST forms, should match the residents' EMRs to ensure staff respond appropriately during medical emergencies. The Social Worker, responsible for assisting residents with their POLST forms, confirmed the accuracy of the DNR wishes on the POLST forms for the three residents. However, the facility's policy on advance directives, which requires that information about whether a resident has executed an advance directive be prominently displayed in the medical record, was not followed. The care plans for the residents included interventions to document the DNR status on the Physician's Order Sheet and inform caregivers, but these were not accurately reflected in the EMRs, leading to the deficiency.
Failure to Notify POA and Hospice Before Hospital Transfer
Penalty
Summary
The facility failed to notify the Power of Attorney (POA), physician, and hospice provider in a timely manner before transferring a hospice resident, identified as R131, to the hospital following a fall incident. R131, who was admitted to hospice care for comfort care due to cerebral vascular disease and other diagnoses, experienced an unwitnessed fall. The nursing progress notes indicated that the fall occurred at 12:25 PM, and the resident was transferred to the hospital for dehydration and abnormal sodium levels. However, the POA was not informed until around 7:08 PM, after the resident had already been admitted to the hospital, contrary to the facility's policy which requires immediate notification of significant changes in condition. The report highlights that the hospice provider was informed of the resident's condition change at 2:45 PM, after the resident had already been sent to the hospital. The hospice nurse stated that the facility should have notified them immediately after the fall, as there was an existing order from the hospice physician not to hospitalize the resident. The Director of Nursing confirmed that the facility's practice is to notify the appropriate parties as soon as any change in resident conditions or hospital transfer occurs. This deficiency in communication and adherence to policy resulted in the resident being hospitalized against the hospice care plan and without the POA's prior knowledge.
Failure to Follow Hospice Physician's Order
Penalty
Summary
The facility failed to adhere to the hospice physician's order for a resident who was not to be hospitalized. The resident, who was under hospice care for comfort care only due to cerebral vascular disease and other medical conditions, experienced an unwitnessed fall. Despite the hospice order indicating 'do not hospitalize,' the facility called 911 and transferred the resident to the hospital. The registered nurse involved stated she was unaware of the order not to hospitalize the resident. The Director of Nursing confirmed that nurses are expected to follow physician orders. The resident's electronic medical records indicated severe cognitive impairment and dependency on staff for daily activities. The hospice nurse was informed of the hospitalization only after the resident had been sent to the hospital. The facility's policy requires physician orders to be followed and the resident's provider to be notified for further medical intervention upon a change in condition.
Unsafe Transfer Practices with Mechanical Lifts
Penalty
Summary
The facility failed to safely transfer residents who required the use of a mechanical lift, affecting three residents. The first resident, R104, had multiple diagnoses including lack of coordination and muscle weakness, requiring a mechanical sit-to-stand lift for transfers. During an observed transfer, the staff used a sling that was not securely fastened, and the knee belt attachment was missing, leading to an unsafe transfer where the resident was not properly supported. The second resident, R32, also required a mechanical lift for transfers due to conditions like muscle weakness and unsteadiness. During her transfer, the staff used a sling that was too large and not securely fastened, despite having access to different sizes. The staff attempted to use a smaller sling but still proceeded with the transfer using an ill-fitting sling, compromising the resident's safety. The third resident, R75, had conditions including hemiplegia and muscle weakness, necessitating the use of a mechanical lift. The staff used a rental machine without a knee belt and a sling that was too loose, failing to provide adequate support. The facility's Director of Nursing and Risk Manager Consultant were unsure about the necessity of knee belts and the appropriate sizing of slings, leading to inconsistent and unsafe transfer practices.
Improper Administration of Extended-Release Antihypertensive Medication
Penalty
Summary
The facility failed to safely administer an extended-release antihypertensive medication to a resident, identified as R92, during a medication administration process. On the morning of February 19, 2025, a registered nurse, V16, crushed and mixed R92's Diltiazem ER 120 mg tablet with applesauce before administering it orally. This action was contrary to the medication's administration instructions, which specified that the tablet should be swallowed whole and not chewed or crushed. The pharmacist, V14, confirmed that crushing the tablet would cause it to lose its extended-release properties, leading to quicker absorption of the dosage. The facility had a policy in place for administering medications safely and timely, as well as a list of medications that should not be crushed, which included Diltiazem. Despite these guidelines, the nurse's action of crushing the extended-release tablet was inconsistent with the manufacturer's instructions and the facility's policy. The resident's order summary report allowed for medications to be crushed if indicated by the manufacturer's guidelines, which was not the case for Diltiazem ER. This incident highlights a significant medication error in the administration process for the resident with hypertensive heart disease.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Winfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wynscape Health & Rehab | 0.6 mi | ★★★★★ | 0 | 0 |
| Dupage Care Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Wheaton Village Nrsg & Rhb Ctr | 1.3 mi | ★★★★★ | 6 | 0 |
| Covenant Living - Windsor Park | 2.5 mi | ★★★★★ | 0 | 0 |
| West Chicago Living And Rehab Center | 2.8 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.